Ruminations by a non-academic general surgeon from the heart of the rust belt.

Thursday, February 28, 2008

Transplant shadiness

This article should be taken with a grain of salt (lacking all the information and details, sensationalist media slant to a controversial topic) but my intial reaction is that something unsavory occured. Basically, a transplant surgeon was a little too involved in expediting a donor's transition from "life" to "death". Now the whole concept of what constitutes "death" is actually a very complicated and controversial issue, especially in an age where advances in medical technology allows patients to be maintained on machines for years and years. In the old days, death was easy to define. The patient stopped breathing, the heart stopped and there wasn't anything you could do about it. You started calling funeral homes. Nowadays, however, "life" can be extended via artificial means. The distinction between life and death blurred as patients, formerly vibrant humans with personality, aspirations and desires, were reduced to existing organisms, maintained by machines and feedings that dripped through tubes into their stomach. The ethical implications of this distinction have become more prominent as transplantation has become the standard of care in dealing with such medical crises as chronic renal failure, liver failure, and heart disease. When is it ok to harvest viable organs from a patient? The infamous quote of "18 people die a day waiting for transplants" has put pressure on society to better define death and to come up with a better way for the equitable distribution of potentially life saving organs. There are two "official" definitions of potential organ donors: brain death and irreversible cardiac death.

In 1981, the President's Commission for the Sudy of Ethical Problems in Medicine and Biomedical and Behavioral Research defined "brain death" as follows:

-Unresponsiveness The patient is completely unresponsive to external visual, auditory, and tactile stimuli and is incapable of communication in any manner.

-Absence of cerebral and brain stem function Pupillary responses are absent, and eye movements cannot be elicited by the vestibulo-ocular reflex or by irrigating the ears with cold water.The corneal and gag reflex are absent, and there is no facial or tongue movement.The limbs are flaccid, and there is no movement, although primitive withdrawal movements in response to local painful stimuli, mediated at a spinal cord level, can occur.

-Apnea Test: An apnea test should be performed to ascertain that no respirations occur at a PCO2 level of at least 60 mmHg. The patient oxygenation should be maintained with giving 100% oxygen by a cannula inserted into endotracheal tube as the PCO2 rises. The inability to develop respiration is consistent with medullary failure.

-Nature of coma must be known Known structural disease or irreversible systemic metabolic cause that can explain the clinical picture.Some causes must be ruled out Body temperature must be above 32 C to rule out hypothermia No chance of drug intoxication or neuromuscular blockade Patient is not in shock

-Persistence of brain dysfunction Six hours with a confirmatory isoelectric EEG or electrocerebral silence, performed according to the technical standards of the American Electroencephalographic SocietyTwelve hours without a confirmatory EEGTwenty-four hours for anoxic brain injury without a confirmatory isoeletric EEG

-Confirmatory tests (are not necessary to diagnose brain death)EEG with no physiologic brain activity No cerebral circulation present on angiographic examination( is the principal legal sign in many European countries) Brain stem-evoked responses with absent function in vital brain stem structures

Brain death is essentialy complete and irreversible cessation of all brain activity. This means that function has ceased in the cerebrum (the seat of consciousness) and also the more primitive, less complex parts of the brain such as the mid brain and brainstem. The patient cannot think, feel, or breath. This does not include people who are in a "persistent vegetative state", where higher cortical function has ceased, but spontaneous breathing and basic reflexes are preserved. After consultation with family members, the decision is made to donate the organs. The donor is wheeled to the OR while still on the ventilator. The heart contnues to beat. The harvest takes place while the organs are still being perfused by circulating blood, therefore making them more viable, less injured, and more easily preserved for use by a recipient. These are the ideal donors. The organs are alive right to the end. Immediately, once detached from the donor body, they are flushed with perfusate and put on ice. Shipped via helicopter to an eager recipient hours away.

Unfortunately, not enough people meet the criteria of brain death to satisfy the demand for organs. Severe head trauma or major strokes can render a person in a periststent vegetative state (PVS), without hope of recovery, without meaningful existence. So the other option is to define death by cessation of cardiac activity. Families who agree to this form of organ donation (non-heart beating donors) must understand that their loved one will be wheeled to the OR whereupon the ventilator will be disconnected and all life support withheld. What happens is, a bunch of medical personnel stand around looking at the monitor, waiting for the heart to go asystolic. When that occurs, the law requires a 5 minute waiting period, "just to make sure", and then the transplant team is allowed to commence the harvest. It sounds, and is, just a little ghoulish. Check out this link for a great selection of philosophic stances on the issues involved in the ethics of donation and transplantation.

My feeling is that it's all much ado about nothing. True, the 5 minute waiting period is arbitrary. But who cares. Why even wait five minutes? Each second of ischemia that passes makes those donor kidneys less likely to be a long term solution to another patient's renal failure. Why go through the charade of making sure various arbitrary criteria are met before proceeding with transplantation? Obviously, the process ought to be conducted in such a way that preserves the dignity of the donor, but not at the expense of wasting organs that could potentially save the life of another sentient, fully conscious human being. Patients in PVS do not have a meaningful existence. There's nothing anyone can say to dissuade me from that stance. Human life transcends mere "existence"; we are self aware beings who think, feel, and create. Simply oxygenating the billions of living cells in our body in not Human Life. It's beneath us.

What happened in California is unclear, but I can guess the basic scenario. The donor came to the OR and was disconnected from the machines but the heart kept beating. Maybe only 20 beats/minute or so, but it wouldn't stop. The official designation of "cardiac death" proved elusive. The transplant team got restless. Maybe they had flown in the middle of the night in a turbo prop plane to harvest the organs themselves. They didn't want to go back empty handed. So the Transplant surgeon enetered the OR and started to give meds; morphine, ativan. The betadine that was alluded to in the article was probably not given systemically (absurd) but maybe he prepped the abdomen and flushed some it through an indwelling feeding tube to make sure everything was sterile and ready to go for the harvest. Who knows. Certainly, given the current legal defintions, the surgeon's presence in the OR prior to the donor's official "death" seems a little unscrupulous. Hastening the demise of a donor, although reasonable from a utilitarian perspective and the perspective of potential recipients, is probably not the sort of activity America/society is ready to condone yet. The fact that the surgeon is up against criminal charges seems ludicrous to me. Did he break protocol and create the perception of a conflict of ineterst? Yes. Did he draw unnecessary, negative attention to a field that is already struggling to attract a big enough pool of donors and perpetuate the stereotype of transplant surgeons as predatory organ harvesters? Of course....

Hopefully something good can come out of it; in the form of a more open dialogue between physicians and patients about end of life issues. More honesty and putting more of the responsibility on the backs of family decision makers will, in the long run, lead us out of any legal quandaries. Why not present the case as such: "Ma'am, your husband is in a persistent vegetative state. You know this because he hasn't responded to you in the four years since the accident. We appreciate your intentions to donate his organs but you need to understand what will happen for this to occur. When the machine is turned off, his heart may stop quickly or it may not. If it slows but doesn't stop, the organs you wish to donate may be jeopardized. Do you wish for us to give medications that will hasten the complete cessation of his heartbeat, or do you wish that let nature take its course?"

I'm a little puzzled by the statement in the article you linked to, saying that Dr. Roozrokh "introduced betadine into the system." Are they trying to say he caused intravenous or oral ingestion? Wouldn't it be kind of crazy to try to poison a person whose organs you want in good condition? That makes it sound like there's a lot of misinformation around.

I always try to avoid this topic because I have a very strong opinion about it but, without going into to detail, let me just say this, after having scrubbed on several, and helped circulate a couple more organ harvests, I made up my mind never to be an organ donor and refused to have anything to do with organ procurement again.

They don't say in the article if the pt. was legally brain dead, you have to infer it, which makes it impossible to take a philosophical stance with the info given. Also, did the MD ask for morphine to slow the pt's respirations or heart rate? (I thought it just slowed respirations...).

It would be ideal if family decision makers took more responsibility for their loved ones' fates, but most brain death cases are devastating traumas. Families are usually too stunned, shocked, wrought with family tensions and grief to make truly informed decisions. Having been involved as the RN go-between for the organ folks, it's troubling to impose the "people are dying every day" urgency guilt trip on families who are struggling with great sadness and loss. I'm starting to think the costs of altering someone's experience of losing their parent or child is not worth the medical benefit of organ transplant.

I mentioned my granddaughter in the comments on your tube feedings post. When she died, her mom and dad offered her organs, bones and even skin for donation and were disappointed that a high fever prevented the use of her tissue for donor use. At the time, they would have allowed the harvesting of any appropriate organs without the five minute bell. Here is her story: http://cookiesoven.blogspot.com/2007/05/life-is-journey.html

The criminalization of medical errors has to stop. We already jail more of our citizens than any country in the world. Transparency seems a new buzz word but reporting,learning from and fixing mistakes must happen. Blame is not the answer

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